United States Medical School Academic Faculty Workforce Diversity, Institutional Characteristics, and Geographical Distributions From 2014-2018.

Purpose Academic healthcare workforce diversity is important in addressing health disparities. Our goal was to evaluate trends and associations in faculty diversity of United States (US) medical schools over a five-year period. Methods We analyzed the Association of American Medical Colleges (AAMC) Faculty Roster data of 151 US medical schools from 2014-2018. Outcome faculty variables were female gender, underrepresented in medicine (UiM), age, and professorial representation. Predictor variables included geographical distributions, and institutional characteristics. Statistical analysis included Jonckheere-Terpstra test, ANOVA, and regression analysis. Results Female faculty increased from 37.6% to 40.4% (p<0.001), senior faculty (age >60 years) from 22.6% to 25.9% (p=0.001) while UiM faculty stayed relatively flat from 9.74% to 10.08% (p=0.773). UiM [adjusted odds ratio (aOR) = 0.39, p=0.015], and female faculty (aOR=0.3, p=0.001) had independently significantly decreased associations with professorial representation, while senior faculty had increased associations (aOR=3.82, p<0.001). Significant independent differences occurred in female, UiM, and professorial faculty distributions within US regions; Hispanic faculty were highest in Southwest (6.57%) and lowest in Midwest region (1.59%), while African-American faculty were highest in Southeast (8.15%) but lowest in the West (3.12%). UiM faculty had significantly independent decreased associations with MD/PhD degree (aOR=0.30, p=0.004) and higher US ranking institutions (aOR=0.45, p=0.009). Conclusions From 2014 to 2018, female faculty increased modestly while the UiM faculty trend remained flat. Female and UiM faculty were less represented at the professor level. UiM faculty were less represented in higher-ranking institutions. Geographic location is associated with faculty diversity.

Feasibility of an Assessment Tool as a Data-Driven Approach to Reducing Racial Bias in Biomedical Publications.

The editorial independence of biomedical journals allows flexibility to meet a wide range of research interests. However, it also is a barrier for coordination between journals to solve challenging issues such as racial bias in the scientific literature. A standardized tool to screen for racial bias could prevent the publication of racially biased papers. Biomedical journals would maintain editorial autonomy while still allowing comparable data to be collected and analyzed across journals. A racially diverse research team carried out a three-phase study to generate and test a racial bias assessment tool for biomedical research. Phase 1, an in-depth, structured literature search to identify recommendations, found near complete agreement in the literature on addressing race in biomedical research. Phase 2, construction of a framework from those recommendations, provides the major innovation of this paper. The framework includes three dimensions of race: 1) context, 2) tone and terminology, and 3) analysis, which are the basis for the Race Equity Vetting Instrument for Editorial Workflow (REVIEW) tool. Phase 3, pilot testing the assessment tool, showed that the REVIEW tool was effective at flagging multiple concerns in widely criticized articles. This study demonstrates the feasibility of the proposed REVIEW tool to reduce racial bias in research. Next steps include testing this tool on a broader sample of biomedical research to determine how the tool performs on more subtle examples of racial bias.

Implementing an Interactive Introduction to Complementary Medicine for Chronic Pain Management Into the Medical School Curriculum.

Introduction: In the setting of the opioid crisis, chronic pain management requires new approaches and open dialogue between physicians and patients to explore evidence-based nonpharmacologic treatments. We developed an educational session on the role of complementary and alternative medicine (CAM) for chronic pain management as part of our larger curriculum on health equity and social justice. Methods: Students and faculty developed a novel educational session for second-year medical students consisting of a lecture and an experiential small-group session immersing the students in CAM. We conducted pre- and postsurveys to assess the students' self-reported learning and impressions of the session. Results: Over the academic years of 2018-2019 and 2019-2020, 345 second-year medical students participated in this mandatory session. In matched pre-and postsession surveys, students rated their knowledge of the evidence behind CAM practices, and reported statistically significant increases in their understanding. When asked about the importance of physician familiarity with common CAM practices, students noted both a high baseline agreement and a statistically significant increase after the session concluded. Familiarity with financial costs of each of the practices also saw statistically significant increases after the session. Discussion: Our results indicated that the session met the educational objectives. A critical part of improving our session between academic years involved gathering feedback and implementing changes based on these suggestions. Our model is easy to implement and replicate at medical schools across the country. Future studies should assess the effects of CAM-focused educational interventions on practices in the clinical setting.

Social Determinants of Health Curriculum Integrated Into a Core Emergency Medicine Clerkship.

Introduction: Demand that health centers address health inequities has led medical schools to emphasize social determinants of health (SDH). The Emergency Department often serves as first (or sole) point of health care access, making it an ideal environment in which to identify/explore SDH. Yet there are few SDH curricula targeting core emergency medicine (EM) clerkships. We describe implementation and outcomes of a three-part SDH curriculum instituted in a 4-week EM clerkship. Methods: We created a longitudinal curriculum aimed at fourth-year medical students in their EM clerkship. Students interviewed patients to discuss social and other influences on their health care and wrote reflections. After this, they discussed their individual cases in small groups, selected one patient, and found literature and strategies/systems to fit the patient's needs. Finally, groups presented their work to student-peers and faculty for discussion. Students were assessed for each activity and surveyed for impact of the curriculum. Results: We evaluated the curriculum, with preliminary data showing a wide range of topics covered. On a 5-point scale (1 = Hardly at All, 5 = To a Very High Degree), students responded with means of 4.4 to "I am able to recognize barriers to health that patients and families face from diverse socio-economic backgrounds" and 4.6 to "I feel it is important to recognize and address the social determinants of health as part of whole patient care." Discussion: This curriculum introduces SDH, uses metacognitive skills across multiple domains, and is feasible and has been well received in an EM clerkship.

Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project.

BACKGROUND: Few patients with dysphagia because of stroke receive early palliative care (PC) to align treatment goals with their values, as called for by practice guidelines, particularly before enteral access procedures for artificial nutrition. MEASURES: To increase documented goals of care (GOC) discussions among acute stroke patients before feeding gastrostomy tube placement. INTERVENTION: We undertook a rapid-cycle continuous quality improvement process with interdisciplinary planning, implementation, and performance review to operationalize an upstream trigger for PC referral prompted by the speech and language pathology evaluation. OUTCOMES: During a six-month period, 21 patients underwent gastrostomy tube placement; 52% had preprocedure GOC discussions postintervention, with the rate of compliance increasing steadily from 13% (11/87, preintervention) to 100% (2/2) in the final two months. CONCLUSIONS/LESSONS LEARNED: We effectively increased documented GOC discussions before feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early PC for stroke patients.

Integrating Social Determinants of Health into Dental Curricula: An Interprofessional Approach.

Approaching patient care from a holistic perspective, incorporating not only the patient's medical and dental history but also psychosocial history, improves patient outcomes. Practitioners should be trained to provide this style of care through inclusive education, including training working on interprofessional teams. A component of this education must incorporate social determinants of health into the treatment plan. Social determinants of health include income, race/ethnicity, education level, work opportunities, living conditions, and access to health care. Education regarding social determinants of health should be woven throughout dental curricula, including hands-on application opportunities. This education must extend to patient care situations rather than be limited to didactic settings. This article explains the need to incorporate social determinants of health into dental education and illustrates how social determinants education is being addressed in two U.S. dental schools' curricula, including how to weave social determinants of health into interprofessional education. These descriptions may serve as a model for curricular innovation and faculty development across the dental education community.

Opportunities and Challenges Facing the Integrated Physician Workforce of Emergency Medicine and Hospice and Palliative Medicine.

BACKGROUND: The American Board of Emergency Medicine joined nine other American Board of Medical Specialties member boards to sponsor the subspecialty of Hospice and Palliative Medicine; the first subspecialty examination was administered in 2008. Since then an increasing number of emergency physicians has sought this certification and entered the workforce. There has been limited discussion regarding the experiences and challenges facing this new workforce. DISCUSSION: We use excerpts from conversations with emergency physicians to highlight the challenges in hospice and palliative medicine training and practice that are commonly being identified by these physicians, at varying phases of their careers. The lessons learned from this initial dual-certified physician cohort in real practice fills a current literature gap. Practical guidance is offered for the increasing number of trainees and mid-career emergency physicians who may have an interest in the subspecialty pathway but are seeking answers to what a future integrated practice will look like in order to make informed career decisions. CONCLUSION: The Emergency and Hospice and Palliative Medicine integrated workforce is facing novel challenges, opportunities, and growth. The first few years have seen a growing interest in the field among emergency medicine resident trainees. As the dual certified workforce matures, it is expected to impact the clinical practice, research, and education related to emergency palliative care.

Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review.

CONTEXT: Emergency department (ED) providers and policy makers are increasingly interested in developing palliative care (PC) interventions for ED patients. Many patients in the ED may benefit from PC screening and referral. Multiple ED-based PC screening projects have been undertaken, but there has been no study of these projects or their effects. OBJECTIVES: To conduct a systematic review and critical analysis to evaluate the methods, tools, and outcomes of PC screening and referral projects in the ED. METHODS: Three reviewers independently selected eligible studies from the PubMed database. Eligible studies evaluated a PC screening tool, assessment, or referral modality aimed at identifying patients appropriate for PC. Four reviewers independently evaluated the final articles. Two reviewers extracted data on study characteristics, methodological quality, and outcomes. RESULTS: Seven studies met inclusion criteria. Each was reviewed for methodological quality and strength. The studies were synthesized using a narrative approach. Each study developed an independent screening or evaluation tool for PC needs. Each required additional ED personnel to perform screening and referral, and success was limited by availability of specialized personnel. All the studies were successful in increasing rates of PC referral. CONCLUSION: We have identified multiple studies demonstrating that screening and referral for PC consultation are feasible in the ED setting. The strengths and limitations of these studies were explored. Further evidence for the development of an effective, evidence-based PC screening, and referral process is needed. We recommend a screening framework based on a synthesis of available evidence.

Palliative care provision in the emergency department: barriers reported by emergency physicians.

BACKGROUND: There is increasing interest in moving palliative care (PC) upstream to the emergency department (ED). However, barriers to PC provision in ED exist and are not yet clearly delineated. OBJECTIVE: To elicit the ED physicians' perceived barriers to provision of PC in the ED. METHODS: ED physicians at an urban, level-1 trauma center completed an anonymous survey. Participants ranked 23 statements on a five-point Likert-like scale (1=strongly disagree to 5=strongly agree). Statements covered four main domains of PC barriers: (1) education and training, (2) communication, (3) ED environment, and (4) personal beliefs. Respondents were also asked if they would initiate a PC consultation for ED-specific clinical scenarios (based on established triggers). RESULTS: Sixty-seven percent (30/45) of eligible participants completed the survey, average age 31 years. Respondents listed two major barriers to ED PC provision: lack of 24 hour availability of PC team (mean 4.4) and lack of access to complete medical records (mean 4.2). Almost all respondents agreed they would initiate a PC consultation for a hospice patient in respiratory distress, and the majority would consult for massive intracranial hemorrhage, traumatic arrest, or metastatic cancer. However inpatient triggers like frequent readmits for organ failure issues, e.g., dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), were rarely chosen for an ED PC consultation. CONCLUSION: We identify two main ED physician-perceived barriers to PC provision: lack of access to medical records and lack of 24/7 availability of PC team. ED physicians may not use the same criteria to initiate PC consultation as used in traditional inpatient PC trigger models. Outlining ED-specific triggers may help streamline the palliative consultation process.

Palliative medicine and geriatric emergency care: challenges, opportunities, and basic principles.

Patients with serious or life-threatening illness are likely to find themselves in an emergency department at some point along their trajectory of illness, and they should expect to receive high-quality palliative care in that setting. Recently, emergency medicine has increasingly taken a central role in the early implementation of palliative care. This article presents an overview of palliative care in the emergency department and describes commonly encountered palliative emergencies, strategies for acute symptom management, communication strategies, and issues related to optimal use of hospice service in the emergency department.

Emergency medicine resident education in palliative care: a needs assessment.

BACKGROUND: Hospice and Palliative Medicine is a newly designated subspecialty of Emergency Medicine (EM). As yet, no well defined palliative care (PC) models for education or training exist. A needs assessment is the first step towards developing a curriculum. GOAL: To characterize emergency physicians' (EP) perceived educational and formal training needs for PC related skills. METHODS: All EM residents and faculty of one academic facility were asked to complete an anonymous needs-assessment survey. Participants were asked to rank statements related to attitudes about PC and rate their formal training and knowledge in 10 aspects of PC using a 5-point Likert-scale. EPs also ranked 4 learning modalities in order of preference and 12 PC educational topics in order of perceived importance in an EM curriculum. RESULTS: Ninety-three percent (42/45) of eligible participants completed the survey (28 residents, 14 faculty). Respondents agreed/strongly agreed that PC skills are an important competence for EM (88%, 37/42) and that they would "like to have more training/education in PC" (79%, 33/42). Respondents also disagreed/strongly disagreed with the statement that "PC consult is called when no more can be done for the patient" (90%, 38/42). Important PC topics identified were pain management, discussing code status, and management of dyspnea and other symptoms in terminal illness. Bedside teaching was listed as the preferred learning modality. EM residents reported minimal training in pain management (46%, 13/28), managing hospice patients (54%, 15/28), withdrawal/withholding life support (54%, 15/28), and managing the imminently dying (43%, 12/28). There was no consistent, significant improvement reported in any domain as training and experience progressed from PGY (postgraduate year) 1 to PGY 4 to attending physician. CONCLUSION: EPs view PC skills as important for EM practice and report that they are not yet adequately educated and trained in providing PC. Domains of particular interest and targeted areas for PC skills training for EPs may include managing hospice patients, withdrawal of life support, prognostication, and pain management.

Self-reported non-adherence to immune-suppressant therapy in liver transplant recipients: demographic, interpersonal, and intrapersonal factors.

Adherence to immune suppressants and follow-up care regimen is important in achieving optimal long-term outcomes after organ transplantation. To identify patients most at risk for non-adherence, this cross-sectional, descriptive study explores the prevalence and correlates of non-adherence to immune-suppressant therapy among liver recipients. Anonymous questionnaires mailed consisted of the domains: (i) adherence barriers to immune suppressants, (ii) immune suppressants knowledge, (iii) demographics, (iv) social support, (v) medical co-morbidities, and (vi) healthcare locus of control and other beliefs. Overall response was 49% (281/572). Data analyzed for those transplanted within 10 yr of study reveal 50% (119/237) recipients or 9.2/100 person years reporting non-adherence. Non-adherence was reported highest in the 2-5 yr post-transplant phase (69/123, 56%). The highest immune-suppressant non-adherence rates were in recipients who are: divorced (26/34, 76%, p=0.0093), have a history of substance or alcohol use (42/69, 61%, p=0.0354), have mental health needs (50/84, 60%, p=0.0336), those who missed clinic appointments (25/30, 83%, p<0.0001), and did not maintain medication logs (71/122, 58%, p=0.0168). Respondents who were non-adherent with physician appointments were more than four and a half times as likely (OR 4.7, 95% CI 1.5-14.7, p=0.008) to be non-adherent with immune suppressants. In conclusion, half of our respondents report non-adherence to immune suppressants. Factors identified may assist clinicians to gauge patients' non-adherence risk and target resources.

Hospice care and the emergency department: rules, regulations, and referrals.

Emergency clinicians often care for patients with terminal illness who are receiving hospice care and many more patients who may be in need of such care. Hospice care has been shown to successfully address the multidimensional aspects of the end-of-life concerns of terminally ill patients: dying with dignity, dying without pain, reducing the burden on family and caregivers, and achieving a home death, when desired. Traditional emergency medicine training may fail to address hospice as a system of care. When they are unfamiliar with the hospice model, emergency clinicians, patients, and caregivers may find it difficult to properly use and interact with these care services. Potential poor outcomes include the propagation of misleading or inaccurate information about the hospice system and the failure to guide appropriate patient referrals. This article reviews the hospice care service model and benefits offered, who may qualify for hospice care, common emergency presentations in patients under hospice care, and a stepwise approach to initiating a hospice care referral in the emergency department.